Casey O’Donnell, President & CEO Impact Services Patrick Keenan, Director of Consumer

1. Combating the Opioid Crisis: What Urban, Suburban, and Rural Communities Can Learn From Philadelphia’s Effort Casey O’Donnell, President & CEO Impact Services Patrick Keenan, Director of Consumer Protections and Policy Pennsylvania Health Action Network (PHAN) Christine Simiriglia, President & CEO Pathways to Housing PA Moderator

8. Testing Mechanisms of Change 2a Social Cohesion SC 2 Collective Efficacy CoE Resilience Re 1 2b Trust Tr

10. Physiology of Trauma: Survival “The fight or flight system”

15. Opioid Response in Rural Communities Pennsylvania’s Medicaid-Informed Response Patrick Keenan, Policy Director, 10/30/2018

16. Agenda • Rural Communities and Opioids • Centers of Excellence • State Opioid Response Grant • Next Steps Stronger Voices for Better Health: The Pennsylvania Health Access Network is a statewide nonprofit, consumer-led organization dedicated ensuring all Pennsylvanians have high quality, equitable, and truly affordable healthcare.

17. Opioids in Rural Areas • According to Overdose Free PA, overdose deaths in rural counties have surged 42 percent, compared to 34 percent for urban counties between 2015 and 2016. • Broad attempts to address things that apply equally to rural and urban communities: • Prescription Drug Monitoring Program • Naloxone Standing Order • Prescribing Guidelines • Disaster Emergency Declaration • Data and the Opioid Command Center • Struggle: less infrastructure to cover bigger areas

18. Opioids in Rural Areas • Medicaid Expansion is one of the largest resources we have in ensuring rural communities have access to treatment. • Every community has people covered through Medicaid with opioid use disorder

19. Centers of Excellence Overview • 45 Centers of Excellence across the Commonwealth • Initial startup grants provided by Pennsylvania under a model that has encouraged flexibility and responsiveness • Movement to incorporate the Centers of Excellence into our Medicaid Managed Care infrastructure • Opportunity to work with the MCOs to expand and continue the work of the Centers of Excellence in a more responsive way to rural communities

20. What does a Centers of Excellence Do?

21. Where are Centers of Excellence?

22. SAMHSAStateOpioid Response • $15 million per year for up to 2 years (more than $1 of every $4 received) for an opioid housing initiative that will fund at least 8 pilot projects • The proposed pilot programs must help individuals to: • Become and remain engaged in evidence-based treatment interventions, • Provide individuals with the necessary support services to maintain housing stability, and • Provide pre-tenancy and tenancy education services. • Includes flexibility for rental assistance • RFA open until 11/20/2018 • Formula drive on diagnosis and overdoes deaths

23. SAMHSAState Opioid Response Rural Urban Allegheny Beaver Berks Bucks Dauphin Delaware Erie Lackawanna Lancaster Lebanon Lehigh Luzerne Philadelphia Westmoreland York • Armstrong • Blair • Butler • Cambria • Cameron • Clearfield • Crawford • Fayette • Greene • Indiana • Lawrence • Mercer • Mifflin • Venango • Washington

24. 2016 Drug-Related Overdose Deaths per 100,000

25. What’s Next?

26. Next Steps • Ensure local lawmakers get the connection between Medicaid Expansion and opioid use disorder treatment • Draw attention to the work already being done by Pennsylvania that applies universally • Find your Center of Excellence and see what it takes do this work • Monitor the rollout of the State Opioid Response grant in your area (and if it’s not in your area, highlight how similar projects could help) • Patrick Keenan, patrick@pahealthaccess.org, (717) 322-5332

27. Housing First Strategies for People with Opioid Use Disorders

28. WHY LOOK AT PHILLY? Because People Come Here for the Heroin. The Heroin Signature Program (HSP) and Heroin Domestic Monitor Program (HDMP) found that the average purity of heroin in Philadelphia is 65.3%-67% and the average price per milligram pure is $0.43-$0.46. These findings suggest that Philadelphia had the purest, cheapest heroin market on the East Coast. (Source: DEA, The Heroin Signature Program and Heroin Domestic Monitor Program, DEA-DCW-DIR-051-16, September 2016.) In 2018, replace the word “purest” with “most lethal”. Philly’s Heroin trade is still the cheapest, but the increased presence of Fentanyl, and recently K2, has replaced purity with death. There were more than 1,200 reported overdose deaths in Philadelphia in 2017 and the number is rising.

29. A Look at Philly’s Homelessnessin the last 5 Years 2014 – 5,377 sheltered, 361 unsheltered 2015 – 5,328 sheltered, 670 unsheltered 2016 – 5,407 sheltered, 705 unsheltered 2017 – 4,737 sheltered, 956 unsheltered 2018 – 5,788 sheltered, 1083 unsheltered The opioid epidemic is driving the increase in unsheltered persons, even while the total number of people experiencing homelessness looks to have decreased.

30. Taking a New Approach…Using a Scattered Site Housing First Model with People with Opioid Use Disorders Focused on Homeless Heroin Users at “Ground Zero” • Housing First apartment units with modified Assertive Community Treatment services that wrap around the person in the community. Street to Home with NO preconditions. • Medical services provided onsite in our clinic – satellite of an FQHC, in the community, and in the form of “house calls”. • On-site/off-site Medication Assisted Treatment through a Centers of Excellence In Opioid Use Disorders Grant (PA DPW). • New and rocky ground for us - Bringing all of our services, including treatment, to the streets.

31. What’s Different? How do you work with opioid users differently, when you are used to working with people with serious mental illness? • Combined core competencies in Housing First with newer ideas encompassing street outreach, needle exchange, Narcan disbursement, and training, along with access to Medication Assisted Treatment that fits the needs of those with chronic homelessness and opioid use. • When people have capacity for treatment, we need immediate access. There are not enough treatment slots to keep up with the need, and the ones that exist will not serve the most in need. We have, by necessity, become treatment providers. Treatment on Demand Flexible Inductions Understanding Relapse

32. • Medical services need to routinely screen for, and we need to be ready to treat, Hep C, HIV and STDs. All are on the rise as sex work becomes the main source of employment for survival with some or our program participants. • Need to look at creative employment options. Many people want to work and need to keep busy. Most won’t pass a drug test as they struggle through the early stages of treatment. • Treatment discharge plans and incarceration releases must coordinate with services. People rotate through and use immediately upon discharge to the streets. If they use the same amount as pre-treatment, they die. • People who use drugs have schedules that revolve around how to keep from getting “dope sick”. We needed to learn how to work on their schedules if we want to effectively serve them.

34. Different Challenges • People are dying, primarily from Fentanyl in their heroin (cocaine, oxycodone, crack and meth), while we are engaging them. • Keeping up with the new drugs and the changes in “heroin” like K2. • There is a lot of “traffic” in, out and around some of our apartments. • Drugs come with danger. We are training more on safety and are role playing different and strange scenarios that are always popping up. • Incidence of trauma (experienced by both participants and staff), grief, burn-out are potentially high. • Focused on continuous support for the direct service staff, and encouraging them to use the supports. • Partnering with other providers offers camaraderie and a shared experience that helps to mitigate the trauma.

35. Successes • Almost 100 people who were prioritized as “most likely to die on the streets”, have been housed. • 93% have retained that housing, thus far (less than 2 years into the program). • 51% are in some form of treatment. Participants trended toward MAT over time with 45% receiving MAT during the first 6 months of housing and with 62% using MAT or abstinent after 6 months of housing. • Vast majority are engaged with primary care and as a result are addressing chronic health conditions such as Hep C, HIV, and severe psychiatric needs. • The pilot was to originally house and serve 75 people. That has been increased to 150!

36. Every provider needs to be talking about and providing training on: • Narcan – Arm everyone: your staff, substance users, their families and friends, landlords, other community workers, churches, EVERYONE. If your organization is risk averse, challenge it. I met with a host of insurance companies and, although a fairly new issue to them, they think that giving staff and clients Narcan and training them how to use it is less of a risk for the agency from a litigation standpoint than having clients overdose. • Trauma – Everyone in our service systems need to be appropriately trained in Trauma Informed Care. Many of these people are traumatized; the type of trauma that your worst nightmares could never come close to. • Harm Reduction – It is no longer a luxury or a nice thing to think about, it is a necessity. Get training. Learn what it is and what it isn’t. Understand its importance in the race to keep people alive. • Fentanyl and K2 – You have to understand the drugs, their interactions, and the subsequent behavioral affects in order to make good decisions around treatment, and in order to keep yourselves and your staff safe.

37. We are available to help with your training and technical assistance needs. https://pathwaystohousingpa.org/Training Training@pathwaystohousingpa.org